Free Complications by Atul Gawande Page B

the mistakes, untoward events, and deaths that occurred on their watch, determine responsibility, and figure out what to do differently next time.
    At my hospital, we convene every Tuesday at five o’clock in a steep, plush amphitheater lined with oil portraits of the great doctors whose achievements we’re meant to live up to. All surgeons are expected to attend, from the interns to the chairman of surgery; we’re also joined by medical students doing their surgery “rotation.” An M & M can include almost a hundred people. We file in, pick up a photocopied list of cases to be discussed, and take our seats. The front row is occupied by the most senior surgeons: terse, serious men, now out of their scrubs and in dark suits, lined up like a panel of senators at a hearing. The chairman is a leonine presence in the seat closest to the plain wooden podium from which each case is presented. In the next few rows are the remaining surgical attendings; these tend to be younger, and several of them are women. The chief residents have put on long white coats and usually sit in the side rows. I join the mass of other residents, all of us in short white coats and green scrub pants, occupying the back rows.
    For each case, the chief resident from the relevant service—cardiac, vascular, trauma, and so on—gathers the information, takes the podium, and tells the story. Here’s a partial list of cases from a typical week (with a few changes to protect confidentiality): a sixty-eight-year-old man who bled to death after heart valve surgery; a forty-seven-year-old woman who had to have a reoperation because of infection following an arterial bypass done in her left leg; a forty-four-year-old woman who had to have bile drained from her abdomen after gallbladder surgery; three patients who had to have reoperations for bleeding following surgery; a sixty-three-year-old man who had a cardiac arrest following heart bypass surgery; a sixty-six-year-old woman whose sutures suddenly gave way in an abdominal wound and nearly allowed her intestines to spill out. Ms. Williams’s case, my failed tracheostomy, was just one case on a listlike this. David Hernandez, the chief trauma resident, had subsequently reviewed the records and spoken to me and others involved. When the time came, it was he who stood up front and described what had happened.
    Hernandez is a tall, rollicking, good old boy who can tell a yarn, but M & M presentations are bloodless and compact. He said something like: “This was a thirty-four-year-old female unrestrained driver in a high-speed rollover. The patient apparently had stable vitals at the scene but was unresponsive, and was brought in by ambulance unintubated. She was GCS 7 on arrival.” GCS stands for the Glasgow Coma Scale, which rates the severity of head injuries, from three to fifteen. GCS 7 is in the comatose range. “Attempts to intubate were made without success in the ER and may have contributed to airway closure. A cricothyroidotomy was attempted without success.”
    These presentations can be awkward. The chief residents, not the attendings, determine which cases to report. That keeps the attendings honest—no one can cover up mistakes—but it puts the chief residents, who are, after all, underlings, in a delicate position. The successful M & M presentation inevitably involves a certain elision of detail and a lot of passive verbs. No one screws up a cricothyroidotomy. Instead, “a cricothyroidotomy was attempted without success.” The message, however, was not lost on anyone.
    Hernandez continued, “The patient arrested and required cardiac compressions. Anesthesia was then able to place a pediatric ET tube and the patient recovered stable vitals. The tracheostomy was then completed in the OR.”
    So Louise Williams had been deprived of oxygen long enough to go into cardiac arrest, and everyone knew that meant she could easily have suffered a disabling stroke or worse. Hernandez concluded with the