by Atul Gawande
Complications
Complications
A Surgeon’s Notes on an Imperfect Science
Atul Gawande
Metropolitan Books
Henry Holt and Company, LLC
Publishers since 1866
175 Fifth Avenue
New York, New York 10010
www.henryholt.com
Metropolitan Books® and ® are registered
trademarks of Henry Holt and Company, LLC.
Copyright © 2002 by Atul Gawande
All rights reserved.
Distributed in Canada by H. B. Fenn and Company Ltd.
Several of these pieces have appeared, in slightly different
form, in The New Yorker and Slate.
Library of Congress Cataloging-in-Publication Data
Gawande, Atul.
Complications: a surgeon’s notes on an imperfect science/Atul Gawande.—1st ed.
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8050-6319-6
ISBN-10: 0-8050-6319-6
1. Surgeons—United States—Biography. 2. Surgery—Anecdotes. I. Title.
RD27.35.G39 A3 2002
617′.092—dc21
[B]
2001055884
Henry Holt books are available for special promotions and premiums. For details contact: Director, Special Markets.
First Edition 2002
Designed by Fritz Metsch
Printed in the United States of America
10 9
FOR KATHLEEN
Contents
Author’s Note
Introduction
Part I—Fallibility
Education of a Knife
The Computer and the Hernia Factory
When Doctors Make Mistakes
Nine Thousand Surgeons
When Good Doctors Go Bad
Part II—Mystery
Full Moon Friday the Thirteenth
The Pain Perplex
A Queasy Feeling
Crimson Tide
The Man Who Couldn’t Stop Eating
Part III—Uncertainty
Final Cut
The Dead Baby Mystery
Whose Body Is It, Anyway?
The Case of the Red Leg
Notes on Sources
Acknowledgments
Complications
Author’s Note
The stories here are true. In order to tell them while protecting people’s confidentiality, however, I have needed to change the names of some patients, their families, and a few of my colleagues. In certain instances, I have also needed to change minor identifying details of individuals. Nonetheless, wherever such changes were made, I have indicated so in the body of the text.
Introduction
I was once on trauma duty when a young man about twenty years old was rolled in, shot in the buttock. His pulse, blood pressure, and breathing were all normal. A clinical assistant cut the clothes off him with heavy shears, and I looked him over from head to toe, trying to be systematic but quick about it. I found the entrance wound in his right buttock cheek, a neat, red, half-inch hole. I could find no exit wound. No other injuries were evident.
He was alert and scared, more of us than of the bullet. “I’m fine,” he insisted. “I’m fine.” But on the rectal exam, my gloved finger came back coated with fresh blood. And when I threaded a urinary catheter into him, bright red flowed from his bladder, too.
The conclusion was obvious. The blood meant that the bullet had gone inside him, through both his rectum and his bladder, I told him. Major blood vessels, his kidney, other sections of bowel may have been hit as well. He needed surgery, I said, and we had to go now. He saw the look in my eyes, the nurses already packing him up to move, and he nodded, almost involuntarily, putting himself in our hands. Then the gurney wheels were whizzing, IV bags swinging, people holding doors open for us to pass through. In the operating room, the anesthesiologist put him under. We made a fast, deep slash down the middle of his abdomen, from his rib cage to his pubis. We grabbed retractors and pulled him open. And what we found inside was . . . nothing.
No blood. No hole in the bladder. No hole in the rectum. No bullet. We peeked under the drapes at the urine coming out of the catheter. It was normal now, clear yellow. It didn’t have even a tinge of blood anymore. We had an X-ray machine brought into the room and got X rays of his pelvis, his abdomen, and also his chest. They showed no bullet anywhere. All of this was odd, to say the least. After almost an hour more of fruitless searching, however, there seemed nothing to do for him but sew him up. A couple days later we got yet another abdominal X ray. This one revealed a bullet lodged inside the right upper quadrant of his abdomen. We had no explanation for any of this—how a half-inch-long lead bullet had gotten from his buttock to his upper belly without injuring anything, why it hadn’t appeared on the previous X rays, or where the blood we had seen had come from. Having already done more harm than the bullet had, however, we finally left it and the young man alone. We kept him in the hospital for a week. Except for our gash, he turned out fine.
Medicine is, I have found, a strange and in many ways disturbing business. The stakes are high, the liberties taken tremendous. We drug people, put needles and tubes into them, manipulate their chemistry, biology, and physics, lay them unconscious and open their bodies up to the world. We do so out of an abiding confidence in our know-how as a profession. What you find when you get in close, however—close enough to see the furrowed brows, the doubts and missteps, the failures as well as the successes—is how messy, uncertain, and also surprising medicine turns out to be.
The thing that still startles me is how fundamentally human an endeavor it is. Usually, when we think about medicine and its remarkable abilities, what comes to mind is the science and all it has given us to fight sickness and misery: the tests, the machines, the drugs, the procedures. And without question, these are at the center of virtually everything medicine achieves. But we rarely see how it all actually works. You have a cough that won’t go away—and then? It’s not science you call upon but a doctor. A doctor with good days and bad days. A doctor with a weird laugh and a bad haircut. A doctor with three other patients to see and, inevitably, gaps in what he knows and skills he’s still trying to learn.
Recently, a boy was flown in by helicopter to one of the hospitals where I work as a resident. Lee Tran, as we can call him, was a small, spiky-haired kid barely out of elementary school. He had always been healthy. But for the previous week, his mother had noticed he had a dry, persistent cough and seemed less energetic than usual. For the last couple days he’d hardly eaten. She thought it was probably a flu. That evening, however, he came to her pale, tremulous, and wheezing, suddenly unable to catch his breath. At a local emergency room, the doctors gave him vaporized breathing treatments, thinking he was having an asthma attack. But then an X ray revealed an immense mass filling the middle of his chest. They got a CT scan for a more detailed picture. In stark black and white, it showed the mass to be a dense, almost football-size tumor enveloping the vessels to his heart, pushing the heart itself to one side, and compressing the airway to both lungs. The tumor had already completely crushed the passage to his right lung, and without air coming through, the lung had collapsed to a gray nubbin on the scan. A sea of fluid from the tumor occupied his right chest instead. Lee was living entirely off his left lung, and the tumor was pressing down on the airway to it, too. The community hospital he was in did not have the resources to deal with this. So the doctors there sent him to us. We had the specialists and high-tech equipment. But that didn’t mean we were sure what to do.
By the time Lee arrived in our intensive care unit, his breathing was a buzzing, reedy str
idor. You could hear it three beds away. The scientific literature is unequivocal about this situation: it is deadly dangerous. Just laying him down could cause the tumor to cut off the remainder of his airway. Giving him sedatives or anesthesia could do the same. Surgery to remove the tumor is impossible. Chemotherapy, however, is known to shrink some of these tumors over the course of a few days. The question was how to buy the child time to find out. It wasn’t clear he’d last the night.
We had two nurses, an anesthesiologist, a pediatric surgery junior fellow, and three residents at the bedside, myself included; the senior pediatric surgeon was on his cell phone, driving in from home; an oncologist was on page. One nurse propped Lee up on pillows to make sure he was as upright as he could be. The other put an oxygen mask on his face and hooked up monitors tracking his vital signs. The boy’s eyes were wide and worried, and his breathing was about twice too fast. His family was still far away, having to travel by ground. But he remained sweetly brave, as children do more often than you’d expect.
My first instinct was that the anesthesiologist should put a stiff breathing tube into the boy’s airway to fix it open before the tumor closed in. But the anesthesiologist thought this was nuts. She’d have to put the tube in without good sedation, with the kid sitting up, no less. And the tumor extended far along the airway. She wasn’t convinced she could reach a tube past it easily enough.
The surgical fellow proposed another idea: if we put a catheter into the boy’s right chest and drained off the fluid filling it, the tumor would tilt away from the left lung. On the phone, however, the senior surgeon was concerned that this could worsen matters. Once you have unsettled a boulder, can you honestly say which way it will roll? No one was thinking of any better options, however. So ultimately he said to go ahead.
I explained to Lee what we were going to do as simply as I could. I doubt he understood. That may have been just as well. After we’d gathered all the supplies we needed, two of us held Lee tight, and another injected a local anesthetic between his ribs, then made a slit with a knife and pushed a foot-and-a-half-long rubber catheter in. Bloody fluid poured out of the tube by the quart, and for a moment I was afraid we’d done something terrible. But as it turned out, we’d done more good than we could have hoped for. The tumor shifted rightward and somehow the airways to both lungs opened up. Instantly, Lee’s breathing became easier and quiet. After watching him a few minutes, so did ours.
Not until later did I wonder about our choice. It was little more than a guess about what to do—a stab in the dark, almost literally. We had no backup plan should disaster have occurred. And when I looked up reports of similar cases at the library afterward, I learned that other options did in fact exist. The safest thing, apparently, would have been to put him on a heart-lung bypass pump like the kind used during cardiac surgery, or at least to have one on standby. Talking with the others about it, though, I found that no one regretted a thing. Lee survived. That was what mattered. And his chemotherapy was now under way. Testing of the fluid showed the tumor to be a lymphoma. The oncologist told me that this gave Lee a better than 70 percent chance of total cure.
These are the moments in which medicine actually happens. And it is in these moments that this book takes place—the moments in which we can see and begin to think about the workings of things as they are. We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.
I am a surgical resident, very nearly at the end of my eight years of training in general surgery, and this book arises from the intensity of that experience. At other times I have been a laboratory scientist, a public health researcher, a student of philosophy and ethics, and a health policy adviser in government. I am also a son of two doctors, a husband, and a parent. I have attempted to bring all of these perspectives to bear on what I have written here. But more than anything, this book comes from what I have encountered and witnessed in the day-to-day caring for people. A resident has a distinctive vantage on medicine. You are an insider, seeing everything and a part of everything; yet at the same time you see it anew.
In some way, it may be in the nature of surgery itself to want to come to grips with the uncertainties and dilemmas of practical medicine. Surgery has become as high tech as medicine gets, but the best surgeons retain a deep recognition of the limitations of both science and human skill. Yet still they must act decisively.
The book’s title, Complications, comes not just from the unexpected turns that can result in medicine but also, and more fundamentally, from my concern with the larger uncertainties and dilemmas that underlie what we do. This is the medicine that one cannot find explained in textbooks but that has puzzled me, sometimes troubled me, sometimes amazed me, as I’ve joined the profession’s ranks. I have divided the book into three sections. The first examines the fallibility of doctors, asking, among other things, how mistakes happen, how a novice learns to wield a knife, what a good doctor is, how it is that one could go bad. The second focuses on mysteries and unknowns of medicine and the struggles with what to do about them; these are the stories of an architect with incapacitating back pain in whom no physical explanation could be found, a young woman with an awful nausea that would not go away, a television newscaster whose blushing became so inexplicably severe that she could no longer function in her job. The third and final section then centers on uncertainty itself. For what seems most vital and interesting is not how much we in medicine know but how much we don’t—and how we might grapple with that ignorance more wisely.
Throughout I’ve sought to show not just the ideas but also the people in the middle of it all—the patients and doctors alike. In the end, it is practical, everyday medicine that most interests me—what happens when the simplicities of science come up against the complexities of individual lives. As pervasive as medicine has become in modern life, it remains mostly hidden and often misunderstood. We have taken it to be both more perfect than it is and less extraordinary than it can be.
Part I
Fallibility
Education of a knife
The patient needed a central line. “Here’s your chance,” S., the chief resident, said. I had never done one before. “Get set up and then page me when you’re ready to start.”
It was my fourth week in surgical training. The pockets of my short white coat bulged with patient printouts, laminated cards with instructions for doing CPR and using the dictation system, two surgical handbooks, a stethoscope, wound-dressing supplies, meal tickets, a penlight, scissors, and about a buck in loose change. As I headed up the stairs to the patient’s floor, I rattled.
This will be good, I tried to tell myself: my first real procedure. My patient—fiftyish, stout, taciturn—was recovering from abdominal surgery he’d had about a week before. His bowel function hadn’t yet returned, leaving him unable to eat. I explained to him that he needed intravenous nutrition and that this required a “special line” that would go into his chest. I said that I would put the line in him while he was in his bed, and that it would involve my laying him out flat, numbing up a spot on his chest with local anesthetic, and then threading the line in. I did not say that the line was eight inches long and would go into his vena cava, the main blood vessel to his heart. Nor did I say how tricky the procedure would be. There were “slight risks” involved, I said, such as bleeding or lung collapse; in experienced hands, problems of this sort occur in fewer than one case in a hundred.
But, of course, mine were not experienced hands. And the disasters I knew about weighed on my mind: the woman who had died from massive bleeding when a resident lacerated her vena cava; the man who had had to have his chest opened because a residen
t lost hold of the wire inside the line which then floated down to the patient’s heart; the man who had had a cardiac arrest when the procedure put him into ventricular fibrillation. But I said nothing of such things when I asked my patient’s permission to do his line. And he said, “OK,” I could go ahead.
I had seen S. do two central lines; one was the day before, and I’d attended to every step. I watched how she set out her instruments and laid down her patient and put a rolled towel between his shoulder blades to make his chest arch out. I watched how she swabbed his chest with antiseptic, injected lidocaine, which is a local anesthetic, and then, in full sterile garb, punctured his chest near his clavicle with a fat three-inch needle on a syringe. The patient didn’t even flinch. S. told me how to avoid hitting the lung with the needle (“Go in at a steep angle; stay right under the clavicle”), and how to find the subclavian vein, a branch to the vena cava lying atop the lung near its apex (“Go in at a steep angle; stay right under the clavicle”). She pushed the needle in almost all the way. She drew back on the syringe. And she was in. You knew because the syringe filled with maroon blood. (“If it’s bright red, you’ve hit an artery,” she said. “That’s not good.”)
Once you have the tip of this needle poking in the vein, you have to widen the hole in the vein wall, fit the catheter in, and thread it in the right direction—down to the heart rather than up to the brain—all without tearing through vessels, lung, or anything else. To do this, S. explained, you start by getting a guidewire in place. She pulled the syringe off, leaving the needle in place. Blood flowed out. She picked up a two-foot-long twenty-gauge wire that looked like the steel D string of an electric guitar, and passed nearly its full length through the needle’s bore, into the vein, and onward toward the vena cava. “Never force it in,” she warned, “and never ever let go of it.” A string of rapid heartbeats fired off on the cardiac monitor, and she quickly pulled the wire back an inch. It had poked into the heart, causing momentary fibrillation. “Guess we’re in the right place,” she said to me quietly. Then to the patient: “You’re doing great. Only a couple minutes now.” She pulled the needle out over the wire and replaced it with a bullet of thick, stiff plastic, which she pushed in tight to widen the vein opening. She then removed this dilator and threaded the central line—a spaghetti-thick, yellow, flexible plastic tube—over the wire until it was all the way in. Now she could remove the wire. She flushed the line with a heparin solution and sutured it to his chest. And that was it.