1. THE PROBLEM OF EXTREME COMPLEXITY

Some time ago I read a case report in the Annals of Thoracic Surgery. It was, in the dry prose of a medical journal article, the story of a nightmare. In a small Austrian town in the Alps, a mother and father had been out on a walk in the woods with their th... ´õº¸±â

1. THE PROBLEM OF EXTREME COMPLEXITY

Some time ago I read a case report in the Annals of Thoracic Surgery. It was, in the dry prose of a medical journal article, the story of a nightmare. In a small Austrian town in the Alps, a mother and father had been out on a walk in the woods with their three- year-old daughter. The parents lost sight of the girl for a moment and that was all it took. She fell into an icy fishpond. The parents frantically jumped in after her. But she was lost beneath the surface for thirty minutes before they finally found her on the pond bottom. They pulled her to the surface and got her to the shore. Following instructions from an emergency response team reached on their cell phone, they began cardiopulmonary resuscitation.

Rescue personnel arrived eight minutes later and took the first recordings of the girl¡¯s condition. She was unresponsive. She had no blood pressure or pulse or sign of breathing. Her body temperature was just 66 degrees. Her pupils were dilated and unreactive to light, indicating cessation of brain function. She was gone.

But the emergency technicians continued CPR anyway. A helicopter took her to the nearest hospital, where she was wheeled directly into an operating room, a member of the emergency crewstraddling her on the gurney, pumping her chest. A surgical team got her onto a heart- lung bypass machine as rapidly as it could. The surgeon had to cut down through the skin of the child¡¯s right groin and sew one of the desk- size machine¡¯s silicone rubber tubes into her femoral artery to take the blood out of her, then another into her femoral vein to send the blood back. A perfusionist turned the pump on, and as he adjusted the oxygen and temperature and flow through the system, the clear tubing turned maroon with her blood. Only then did they stop the girl¡¯s chest compressions.

Between the transport time and the time it took to plug the machine into her, she had been lifeless for an hour and a half. By the two- hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. It was her first organ to come back.

After six hours, the girl¡¯s core reached 98.6 degrees, normal body temperature. The team tried to shift her from the bypass machine to a mechanical ventilator, but the pond water and debris had damaged her lungs too severely for the oxygen pumped in through the breathing tube to reach her blood. So they switched her instead to an artificial- lung system known as ECMO? extracorporeal membrane oxygenation. To do this, the surgeons had to open her chest down the middle with a power saw and sew the lines to and from the portable ECMO unit directly into her aorta and her beating heart.

The ECMO machine now took over. The surgeons removed the heart- lung bypass machine tubing. They repaired the vessels and closed her groin incision. The surgical team moved the girl into intensive care, with her chest still open and covered with sterile plastic foil. Through the day and night, the intensive care unit team worked on suctioning the water and debris from her lungs with a fiberoptic bronchoscope. By the next day, her lungs had recovered sufficiently for the team to switch her from ECMO to a mechanical ventilator, which required taking her back to the operating room to unplug the tubing, repair the holes, and close her chest.

Over the next two days, all the girl¡¯s organs recovered? her liver, her kidneys, her intestines, everything except her brain. A CT scan showed global brain swelling, which is a sign of diffuse damage, but no actual dead zones. So the team escalated the care one step further. It drilled a hole into the girl¡¯s skull, threaded a probe into the brain to monitor the pressure, and kept that pressure tightly controlled through constant adjustments in her fluids and medications. For more than a week, she lay comatose. Then, slowly, she came back to life. ´Ý±â

The "New York Times" bestselling author of "Better" and "Complications" reveals the surprising power of the ordinary checklistWe live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced te... ´õº¸±â

The "New York Times" bestselling author of "Better" and "Complications" reveals the surprising power of the ordinary checklist

We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies--neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy in the humblest and simplest of techniques: the checklist. First introduced decades ago by the U.S. Air Force, checklists have enabled pilots to fly aircraft of mind-boggling sophistication. Now innovative checklists are being adopted in hospitals around the world, helping doctors and nurses respond to everything from flu epidemics to avalanches. Even in the immensely complex world of surgery, a simple ninety-second variant has cut the rate of fatalities by more than a third.

In riveting stories, Gawande takes us from Austria, where an emergency checklist saved a drowning victim who had spent half an hour underwater, to Michigan, where a cleanliness checklist in intensive care units virtually eliminated a type of deadly hospital infection. He explains how checklists actually work to prompt striking and immediate improvements. And he follows the checklist revolution into fields well beyond medicine, from disaster response to investment banking, skyscraper construction, and businesses of all kinds.

An intellectual adventure in which lives are lost and saved and one simple idea makes a tremendous difference, "The Checklist Manifesto" is essential reading for anyone working to get things right.

Atul Gawande is the author of "Better" and "Complications." He is also a MacArthur Fellow, a general surgeon at the Brigham and Women's Hospital in Boston, a staff writer for "The New Yorker," and an assistant professor at Harvard Medical School and the Harvard School of Public Health. He lives with his wife and three children in Newton, Massachusetts.

Taxed with great and increasing complexity, even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies--neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy to this disquieting problem in the humblest and simplest of techniques: the checklist.
First introduced decades ago by the U.S. Air Force, checklists have enabled pilots to fly aircraft of mind-boggling sophistication. Now innovative checklists are being adopted in hospitals around the world, helping doctors and nurses respond to everything from flu epidemics to avalanches. Even in the immensely complex world of surgery, a simple ninety-second variant has cut the rate of fatalities by more than a third.
Gawande provides real testimonials in the form of riveting stories. In Austria, an emergency checklist saved a drowning victim who had spent half an hour underwater. In Michigan, a cleanliness checklist in intensive care units virtually eliminated a type of deadly hospital infection. He explains how checklists actually work to prompt striking and immediate improvements to procedure and increase positive results, even under the most precarious circumstances. And he follows the checklist revolution into fields well beyond medicine, from disaster response to investment banking, skyscraper construction, and businesses of all kinds.
Gawande shows how one simple idea can make a tremendous difference. "The Checklist Manifesto" is essential reading for anyone working to get things right. "Few medical writers working today can transmit the gore-drenched terror of an operation that suddenly goes wrong--a terror that has a special resonance when it is Dr. Gawande himself who makes the initial horrifying mistake. And few can make it as clear as he can what exactly is at stake in the effort to minimize calamities."--"The New York Times" "Few medical writers working today can transmit the gore-drenched terror of an operation that suddenly goes wrong--a terror that has a special resonance when it is Dr. Gawande himself who makes the initial horrifying mistake. And few can make it as clear as he can what exactly is at stake in the effort to minimize calamities."--"The New York Times" "Even skeptical readers will find the evidence staggering . . . Thoughtfully written and soundly defended, this book calls for medical professionals to improve patient care by adopting a basic, common-sense approach."--"The Washington Post" "A persuasive champion of his cause."--"The Economist" "Gawande deftly weaves in examples of checklist successes in diverse fields like aviation and skyscraper construction . . . Fascinating reading."--"The New York Times Book Review" "This is a brilliant book about an idea so simple it sounds dumb until you hear the case for it. Atul Gawande presents an argument so strong that I challenge anyone to go away from this book unconvinced."--"The Seattle Times" "Fascinating . . . presents a convincing case that adopting more checklists will surely help."--"Bloomberg News" "Gawande argues convincingly and eloquently."--"San Francisco Chronicle" "I read "The Checklist Manifesto" in one sitting yesterday, which is an amazing tribute to the book that Gawande has crafted. Not only is the book loaded with fascinating stories, but it honestly changed the way I think about the world. It is the best book I've read in ages."--Steven Levitt, author of "Freakonomics"
"A vivid, punchy exposition of an intriguing idea: that by-the-book routine trumps individual prowess."--"Publishers Weekly" ´Ý±â