checklists

A simple procedure borrowed from the airline industry and a bit of humility has ensured many more patients survive
The biggest problem in giving patients the best medical care is the sheer complexity of what we’re trying to do. The case of a three-year-old girl taught me how to take care of somebody who has drowned.
She had been out for a walk with her parents one winter day in Austria. It was one of those terrible things: the parents lost sight of her for a moment and the next thing, they saw her on the surface of an icy fishpond. She fell through the ice and was gone. They jumped in but could not find her. It was more than 30 minutes before they felt a limb at the bottom of the pond and pulled her out. But, of course, by then she wasn’t breathing.
They called the local emergency services, and the operator told them how to start doing cardiopulmonary resuscitation, or CPR. The rescue team arrived eight minutes later and took the first vital signs. The girl’s temperature was just 66F, more than 30F below normal. She had no pulse and her pupils were fixed wide open. That means the brain is gone.
She was flown by helicopter to the nearest hospital. They bypassed A&E and went straight to the operating theatre to begin warming her. Two hours later, they’d raised her temperature by ten degrees — and her heart began to beat. One organ back. They then tried putting her on a ventilator. But it didn’t work. Her lungs were too full of pond water and debris for oxygen to get through.
So they tried a different machine. It’s an artificial lung called an extracorporeal membrane oxygenator. For this, they had to open her chest with a saw and plug the machine directly into her heart, but it got oxygen to her bloodstream. For 24 hours, the team worked to clear her lungs, and finally the oxygen got through. Two organs back.
After two days, they’d got all her organs back except one: her brain. The neurosurgery team drilled a hole in her skull and inserted a probe to gauge the pressure in her brain so they could dial her fluids and drugs up and down until they lowered it. She remained comatose for a week. But then her pupils began to react to light. Then she began to breathe on her own. And then one day, she simply awoke. Her eyes opened and she was there.
Two weeks later, she went home. And two years later, they found her physical and neurological capabilities were exactly as they were supposed to be. She was, in other words, after all of that, just like any other five-year-old girl that you and I know.
Her lucky escape was 15 years ago. The extent of what was required to pull it off seemed almost impossible. There were dozens, probably hundreds, of people involved in her care, and any one of them could have made a small mistake. If one nurse forgot to wash his or her hands, it would have been over.
The 20th century has given us a volume of knowledge and skill greater than any individual can hold in their own head or know how to deliver alone. How do we solve that? Simply telling or ordering people to do certain things isn’t very effective. We need to make doing the right thing the norm. We do that through systems. And those systems can be as simple as a checklist. The important thing is to make it easy for everybody to follow.
My team was approached by the World Health Organisation several years ago with a project designed to reduce deaths in surgery. I thought: how can you possibly do that? But we worked with a safety engineer from the airline industry to design what emerged as a checklist. It had some dumb things — “Do you have the right side of the body you’re operating on?” — but the most powerful components were “Does everybody on the team know each other’s name and role?” and “Has the surgeon briefed the team on the goals of the operation?”
Only then do you begin.
After we had tested the checklist in eight cities around the world — including St Mary’s Hospital in west London — the average reduction in deaths was 47 per cent. In Scotland, it has saved the lives of 9,000 people over the past four years.
Clearly, it’s not just the checklist. The hardest part is making even the most experienced people feel enough humility to accept that they can make mistakes. We fear these kinds of system. We fear that it’ll lead to a loss of daring, a loss of heroism.
When we surveyed surgeons three months after they introduced checklists, we found that 20 per cent or more really disliked them. Then we asked: “If you’re having an operation, would you want the team to use the checklist?” And 94 per cent did. What you discover is that discipline makes daring possible.
When I read about the drowned girl, I was puzzled to know how they discovered what to do in such a small hospital — it was Klagenfurt in Austria. Every year, large numbers of people were admitted after being caught in avalanches, which is like being drowned. Markus Thalmann, a cardiac surgeon at the hospital, was convinced he could save them.
He had a plan. It required speed. You needed an array of things at the ready: the pump, the trauma surgeon, cardiac surgeon, anaesthetist. But there was always a problem: the anaesthetist would be at home 30 minutes away, or the pump wasn’t be ready. He tried to fix things in the usual way that surgeons do: by yelling at everyone.
That, of course, didn’t work. So he decided to try something new. He made a checklist. Interestingly, he gave it to the person who had the least power in the system: the telephone operator. When the operators got the call, they had the authority to activate the checklist. They could call the doctors at home and tell them, “You need to come in now.” They’d tell the engineer to get the machine ready. And this was the way they had their first survivor — that little girl. Since then, I learnt, they’d had many. He told me about the most recent.
A mother driving her daughter on a mountain road lost control of her car, which crashed through a barrier. The mother died instantly. The car fell into a river and the emergency crews arrived just in time to see it disappear under the water. They managed to cut open the car and get the girl out. By then she had gone for more than half an hour without breathing.
But, after that, the system at the hospital went like clockwork. The teams were ready. They went straight to the operating theatre. As her body warmed up, her heart came back. In the ICU, a ventilator, fluids and drugs kept her going while the rest of her body recovered. The next day, the doctors removed her lines and tubes. The day after that, she was sitting up in bed, ready to go home.
Atul Gawande is presenting this year’s BBC Reith lectures on the future of medicine, which begin on Radio 4 on Tuesday. He is a surgeon, public health researcher and author of Being Mortal: Illness, Medicine and What Matters in the End