Atul Gawande - Complications

from the publisher:
Sometimes in medicine the only way to know what is truly going on in a patient is to operate, to look inside with one's own eyes. This book is exploratory surgery on medicine itself, laying bare a science not in its idealized form but as it actually is -- complicated, perplexing, and profoundly human.

Atul Gawande offers an unflinching view from the scalpel's edge, where science is ambiguous, information is limited, the stakes are high, yet decisions must be made. In dramatic and revealing stories of patients and doctors, he explores how deadly mistakes occur and why good surgeons go bad. He shows what happens when medicine comes up against the inexplicable: an architect with incapacitating back pain for which there is no physical cause; a young woman with nausea that won't go away; a television newscaster whose blushing is so severe that she cannot do her job. And in a richly detailed portrait of both the people and the science, Gawande also ponders the human factor that makes saving lives possible.

At once tough-minded and humane, Complications is a new kind of medical writing, nuanced and lucid, unafraid to confront the conflicts and uncertainties that lie at the heart of modern medicine, yet always alive to the possibilities of wisdom in this extraordinary endeavor.

"Complications is a book about medicine that reads like a thriller. Every subject Atul Gawande touches is probed and dissected and turned inside out with such deftness and feeling and counterintuitive insight that the reader is left breathless." --Malcolm Gladwell, author of The Tipping Point

"No one writes about medicine as a human subject as well as Atul Gawande. His stories are scary, funny, absorbing, and always touched with both a tender conscientiousness and an alert, hyper-intelligent skepticism. He captures, as no one else has, the doubleness of doctoring: what it feels like to see other people as fascinating, intricate, easily breakable machines and, at the same time, as mirror images of one's own self. Complications is a uniquely soulful book about the science of mending bodies." --Adam Gopnik, author of Paris to the Moon

"Complications is a literary version of an informed consent form. It's refreshingly honest, if not always reassuring. Some people still prefer to think of surgeons as infallible gods. But Atul Gawande is a rare and wonderful storyteller who portrays his profession with bravery and humanity." --Ellen Goodman, Pulitzer prize-winning columnist and coauthor of I Know Just What You Mean

"Gawande's prose, much like the scalpel he wields, is precise, daring but never reckless. But it is after he exposes what lies beneath that we see the full measure of Gawande's gift: his compassion, his honesty, and a trademark hypervigilance paired with scholarship. Much like reading George Orwell, the reader emerges entertained, enlightened, transformed and immensely satisfied." --Abrahan Verghese, author of My Own Country and The Tennis Partner

Atul Gawande is a surgical resident at a hospital in Boston and a staff writer on medicine and science for The New Yorker. He received his M.D. from Harvard Medical School and an M.P.H. from the Harvard School of Public Health. His writing has appeared in The Best American Science and Nature Writing 2000, the New Yorker essay collection In Sickness and in Health, and Slate. Gawande lives with his wife and three children in Newton, Massachusetts.



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 refractors 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 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.