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By Root 850 0

introducing ourselves—“Atul Gawande, surgeon.” “Rich Bafford, surgery resident.” “Sue Marchand, nurse”—you could feel the room snapping to attention. We confirmed the patient’s name on his ID bracelet and that we all agreed which adrenal gland was supposed to come out. The anesthesiologist confirmed that he had no critical issues to mention before starting, and so did the nurses. We made sure that the antibiotics were in the patient, a warming blanket was on his body, the inflating boots were on his legs to keep blood clots from developing. We came into the room as strangers. But when the knife hit the skin, we were a team.

As a result, when I made the tear and put disaster upon us, everyone kept their head. The circulating nurse called an alarm for extra personnel and got the blood from the blood bank almost instantly. The anesthesiologist began pouring unit after unit into the patient. Forces were marshaled to bring in the additional equipment I requested, to page the vascular surgeon I wanted, to assist the anesthesiologist with obtaining more intravenous access, to keep the blood bank apprised. And together the team got me—and the patient—precious time. They ended up transfusing more than thirty units of blood into him—he lost three times as much blood as his body contained to begin with. And with our eyes on the monitor tracing his blood pressure and my hand squeezing his heart, it proved enough to keep his circulation going. The vascular surgeon and I had time to work out an effective way to clamp off the vena cava tear. I could feel his heart begin beating on its own again. We were able to put in sutures and close the hole. And Mr. Hagerman survived.

I cannot pretend he escaped unscathed. The extended period of low blood pressure damaged an optic nerve and left him essentially blind in one eye. He didn’t get off the respirator for days. He was out of work for months. I was crushed by what I had put him through. Though I apologized to him and carried on with my daily routine, it took me a long time to feel right again in surgery. I can’t do an adrenalectomy without thinking of his case, and I suspect that is good. I have even tried refining the operative technique in hopes of coming up with better ways to protect the vena cava and keep anything like his experience from happening again.

But more than this, because of Mr. Hagerman’s operation, I have come to be grateful for what a checklist can do. I do not like to think how much worse the case could have been. I do not like to think about having to walk out to that family waiting area and explain to his wife that her husband had died.

I spoke to Mr. Hagerman not long ago. He had sold his company with great success and was in the process of turning another company around. He was running three days a week. He was even driving.

“I have to watch out for my blind spot, but I can manage,” he said.

He had no bitterness, no anger, and this is remarkable to me. “I count myself lucky just to be alive,” he insisted. I asked him if I could have permission to tell others his story.

“Yes,” he said. “I’d be glad if you did.”

NOTES ON SOURCES

INTRODUCTION

7 “In the 1970s”: S. Gorovitz and A. MacIntyre, “Toward a Theory of Medical Fallibility,” Journal of Medicine and Philosophy 1 (1976): 51–71.

9 “The first safe medication”: M. Hamilton and E. N. Thompson, “The Role of Blood Pressure Control in Preventing Complications of Hypertension,” Lancet 1 (1964): 235–39. See also VA Cooperative Study Group, “Effects of Treatment on Morbidity of Hypertension,” Journal of the American Medical Association 202 (1967): 1028–33.

10 “After that, survival”: R. L. McNamara et al., “Effect of Door-to-Balloon Time on Mortality in Patients with ST-Segment Elevation Myocardial Infarction,” Journal of the American College of Cardiology 47 (2006): 2180–86.

10 “In 2006”: E. H. Bradley et al., “Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction,” New England Journal of Medicine 355 (2006): 2308–20.

10 “Studies have found”: E. A. McGlynn et al., “Rand