Atul You What

The Daily Show With Jon Stewart	Mon - Thurs 11p / 10c
Atul Gawande
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Daily Show

It's not that I'd argue against surgical checklists. Nor do I take issue with the data about lives saved (although I'd like to see them in detail.) It's just that it blows my mind.

Maybe it's me; maybe it's my training. Having started work in the surgical field forty years ago, it astounds me that such a simple checklist can save so many lives at so many institutions. What it tells me is that there are a lot of inferior institutions out there, and inferior surgeons. Dr G's institution included, maybe. Because the sorts of errors the checklist is said to prevent ought not need such a checklist in the first place. People ought to perform better than that. That they don't, that they need such a procedure, says a lot about our health care system. None of it good.

In the thousands upon thousands of operations I did, I ALWAYS spoke to the patient while s/he was fully awake in the pre-op area. (Okay, there may have been rare cases when I didn't, due to some sort of emergency or other. Rare.) In addition to re-telling them the plan, soliciting last-minute questions, trying to reassure them, I'd ALWAYS state the operation and, when relevant, point to -- touching, usually -- the side on which we'd be operating. Breast, hernia, whatever. In the operating room, I'd ALWAYS confirm with the anesthesia person or circulating nurse that an ordered pre-operative medication had been given. If there were special instruments I'd be needed, I'd ALWAYS check to be sure they were there.

Since the 70's, I'd been doing a checklist.

So here's my point: how can it possibly be that -- in academic centers, ferchrissakes -- such behavior hasn't been routine? If checklists have made such a big difference, then the hospitals that are using them and the surgeons operating there shouldn't have been in the business in the first place.

Dr Gawande -- whom I admire, whose books I've read, whose endorsement I sought for my own book (I sent him some snippets, which he said he enjoyed, but he said he had so many endorsement requests that he'd stopped doing them) -- analogizes to pre-flight checklists pilots use. He says things have gotten so complex in the OR that it's not reasonable to go through steps before starting. Fair enough. But the checklist hardly reflects that complexity. Here it is:

It's neither comprehensive, nor, one would think, beyond the expected routines. (Okay, I didn't always introduce myself or the members of the team. Maybe because we worked together all the time: maybe that's part of their problem?)

I'm not saying it's unnecessary. I'm just saying it's shameful that it is.

(I did write about this once before. There's not a lot new in this post, I guess. It's just that every time I see something about it -- the above clip was last night -- it tweaks me again. And it makes me realize how much, in many ways, I miss doing what I did. And how much, in many other ways, I'm glad I'm outta there.)

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Check, Please

This is about one of those surgical papers that makes me scratch my head. Or shake it, or press on it from both sides. Can it really be true? If so, why?

It reminds me of another one, a few years back, that touted using a laser in performing a mastectomy. Since we started doing it, the authors said without evident embarrassment, our transfusion rate decreased from four units per case to two, and our hospital stays went from nine to five days. Wow. At the time I'd done several outpatient mastectomies (at the patients' request, may I add); rarely did any of my patients need or want to stay in the hospital longer than a day or two; and I never even ordered blood for the operation, much less used it. Who the hell were those guys, and what the hell kind of surgeons were they?

It's with that in mind that I mention a recent and much talked-about report which shows an impressive and universal (throughout the study hospitals) lessening of surgical deaths and complications by the use of a simple checklist before and after the operation. I certainly don't disapprove of such checklists; variations thereon are more or less universal in American operating rooms nowadays. Where I come up a little short, understanding/explanation-wise, is here: first, the "major complication" rate before the study was 11%, and death rate was 1.5%. With the checklist, they diminished to 7% and .8%. Still pretty high, if you ask me: if I'd had numbers like the pre-study ones in my practice, I'd have been kicked off staff. Summarily. With the post-study ones, I might be on probation. Second, the checklist is so rudimentary that I'm at a loss to understand why it works. And, like some, I question whether it's even true. But there it is.

Without doubt, taking care to eliminate wrong operation or wrong-sided surgery is essential (even though the incidence is very low.) Counting sponges and instruments at the end of a case is routine, and has been approximately forever. (The second link indicates that compliance before the study was only 34%; even more remarkably, during the study it was only 57%! Once again: who are these people?) Similarly, if the anesthesia personnel aren't making sure they have what they need ahead of time, and if the surgeon hasn't thought about whether s/he needs blood available or antibiotics administered, there's something wrong. But there's nothing wrong with checking to be sure.

In the first link, one can watch (not-particularly-gripping) video. It provides some clues. Part of the routine is to introduce the members of the team to one another, which hardly seems protective of anything, per se, but suggests a group of people not used to working together. And the surgeon mentions that the operation, a routine hernia, will probably be under an hour. Probably? How about fifteen or twenty minutes? Both of those factors suggest a training program, where there's typically no continuity of personnel, and where operations take longer than "normal." Each of those contributes to increased complication rates. As does the fact that in teaching settings there are usually two or three extraneous people scrubbed in, peering into the hole, scratching their asses, etc.

You'd think that in taking a right turn from my usual targets, I'd have some sort of wisdom to impart at this point (although, one might ask, why start now?); I really don't. I applaud all attempts to improve the quality of health-care delivery; it's just that this particular approach puzzles me. Comparably, it's as if all a pilot were required to do before take-off is to make sure the crew knew each other, confirmed the destination and that the doors were shut.

If that makes a difference, we're in bigger trouble than I thought.

Or maybe I'm missing something.

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