Authors: Atul Gawande
A Surgeon’s Notes on an Imperfect Science
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Copyright © 2002 by Atul Gawande
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Several of these pieces have appeared, in slightly different
The New Yorker
Library of Congress Cataloging-in-Publication Data
Complications: a surgeon’s notes on an imperfect science/Atul Gawande.—1st ed.
Includes bibliographical references and index.
1. Surgeons—United States—Biography. 2. Surgery—Anecdotes. I. Title.
RD27.35.G39 A3 2002
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he 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.
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
.” 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 stridor. 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
lungs opened up. Instantly,
Lee’s breathing became easier and quiet. After watching him a few minutes, so did ours.