I had one case in which I know for sure the checklist saved my patient's life. Mr Hagerman, as we'll call him, was a 53-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 tumour growing inside it called a pheochromocytoma. Tumours 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 40 adrenal tumours without complications.
So when Mr Hagerman came to see me about this strange mass, 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 tumour with instruments I observed on a videomonitor using a fibre-optic camera we put inside Mr Hagerman. All was going smoothly. I was able to lift the liver out of the way, and underneath I found the soft, tan yellow mass, like the yolk of a hard-boiled egg. Painstakingly, I began dissecting it free of the vena cava, and it didn't seem unusually difficult. I'd gotten the tumour 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 60 seconds and went into cardiac arrest. I made a 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 the 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 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 prepare for, I said: "I don't expect much blood loss. I've never lost more than 100cc's [100ml]."
I was confident. I was looking forward to this operation. But I added that the tumour was pressed up against the vena cava and that significant blood loss remained 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. As a result, from this one step alone, the checklist saved my patient's life.
Just as powerful, though, was the effect the routine of the checklist – the discipline – had on us. Of all the people in the room as we started that operation – the anaesthesiologist, the nurse anaesthetist, the surgery resident, the scrub nurse, the circulating nurse, the medical student – I had worked with two before, and I knew only the resident well. But as we introduced 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 to come out. The anaesthesiologist confirmed 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 anaesthesiologist began pouring unit after unit into the patient. Forces were marshalled to bring in the additional equipment I requested, to page the vascular surgeon I wanted, to assist the anaesthesiologist 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 30 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 apologised 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.
But more than this, because of Mr Hagerman's operation, I have come to be grateful for what a checklist can do. 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."
'The Checklist Manifesto: How to Get Things Right' by Atul Gawande is published by Profile Books (12.99)
Safer surgery: A clinical innovation
Not many surgeons are comfortable discussing their mistakes, especially the catastrophic ones. But Atul Gawande is not an ordinary surgeon. As associate professor at the Harvard School of Public Health, a columnist for the New Yorker and the author of three books, he has become an international ambassador for improved safety in surgery.
The catastrophe he describes on these pages, taken from his latest book, has a message. It is that for all the stupendous medical know-how accumulated at the beginning of the 21st century failures are still frequent. The reason is increasingly evident – the volume and complexity of what is known exceeds the capacity of surgical teams to deliver it.
Among 8 million operations carried out in the UK in 2007, equivalent to one for every eight people in the population, there were 129,000 reported incidents in which patients were put at risk, according to the National Patient Safety Agency.
Atul Gawande has pioneered a strategy to reduce this toll which is now being introduced in every hospital in England. It is the checklist – a series of basic checks (Is this the right patient? Is this the right limb?) are run through before each operation, in the same way that pilots check their aircraft before take off. When the checklist was piloted by the World Health Organisation in eight hospitals around the world last year, it cut deaths and complications by more than a third.
Described as the biggest clinical innovation in 30 years, it has been rolled out through the NHS and is now being used in 90 per cent of operating theatres in England, according to the Department of Health. From yesterday, every hospital is expected to use it in every operation. Anne Pullyblank, consultant surgeon at the North Bristol NHS Trust, who has pioneered an adapted form of the checklist, said: "I will probably save more lives by checking that every patient gets the right treatment... than [with] any piece of research."
Jeremy Laurance, Health Editor